THE 'EDGE REPORT BLOG

How Successful Health Plans Transform Their Business

The health insurance industry is constantly evolving with the introduction of new regulations, the need to adopt value-based reimbursement (VBR) models, and changing customer expectations. Innovative health plans are transforming their business operations — discovering ways to efficiently tackle these challenges and better meet market demand while reducing costs.

Business transformation requires your organization to objectively examine the people, processes, and technologies that drive your core business, with a focus on automation.

A recent survey revealed that competitive pressures (39%), lack of alignment between IT and the business (39%), followed by member satisfaction and managing costs (37%), are the top three challenges facing their organizations today. This is a notable shift from a 2018 executive survey, where lack of alignment between IT and the business ranked at the bottom (22%). Payers are waking up to the fact they must meet consumer demands to remain competitive, and IT must actively participate in achieving these business goals.

Changing market dynamics continue to encourage health plans to grow their businesses, develop new services, increase membership, and ensure a positive member experience. To achieve these goals, the first step is to find a modern technology that helps plans quickly adopt new business models and automate processes to achieve optimum operational efficiency.

If your organization wants to take the first step in the transformation, ask yourself a few basic questions:

Can my current system:

  • Improve my member satisfaction?
  • Improve my claims adjudication rates, speed, and efficiency?
  • Help me launch new plans/benefits/services in a matter of hours?
  • Help me easily expand into new geographies?
  • Help me reduce my claims backlog?

If you answered no to any of the above questions, your first transformation opportunity might reside in your core administration system.

Legacy core administration systems were designed in a different era. Today, members and providers demand to access real-time information online, and plans must be responsive to all inquiries. While many health insurers have made significant investments to modernize and integrate these systems, their architecture does not offer the flexibility and speed needed to succeed in today’s marketplace.

Do not underestimate the need for flexibility. A health plan must be agile enough from a people, process, and technology perspective to proactively embrace new regulations and reimbursement models, exceed customer expectations and develop and introduce new plans/benefits/services fast.

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